The Effect of Mental Status Screening on the Care of Elderly Emergency Department Patients

GERIATRICS/ORIGINAL RESEARCH The Effect of Mental Status Screening on the Care of Elderly Emergency Department Patients Fredric M. Hustey, MD Stephen W. Meldon, MD Michael D. Smith, MD Carolyn K. Lex, BS From the Department of Emergency Medicine, The Cleveland Clinic Foundation (Hustey); the Department of Emergency Medicine, MetroHealth Medical Center (Meldon); and Case Western Reserve University School of Medicine (Smith, Lex), Cleveland, OH. Copyright 2003 by the American College of Emergency Physicians. 0196-0644/2003/$30.00 + 0 doi:10.1067/mem.2003.152 Study objectives: We determine the effect of screening examinations for mental status impairment on the care of elderly patients in the emergency department and prospectively assess recognition of mental status impairment by emergency physicians. Methods: We performed a prospective cross-sectional study. Patients were 70 years of age or older and presented to an urban teaching hospital ED over a 17-month period. Mental status impairment screening comprised the Orientation Memory Concentration examination for cognitive impairment and the Confusion Assessment Method for delirium. Emergency physicians who were blinded to the patient s screening results were interviewed to assess recognition of mental status impairment, dispositions, and referrals. Results of mental status impairment screens were then given to emergency physicians, and emergency physicians were reinterviewed regarding any change in care. Results: Two hundred seventy-one of the 327 eligible patients were enrolled. Seventy-four (27%; 95% confidence interval [CI] 22% to 33%) patients had impaired mental status. Nineteen (7%; 95% CI 4% to 11%) had delirium, and 55 (20%; 95% CI 16% to 25%) had cognitive impairment without delirium. Mental status impairment was recognized in only 28 (38%; 95% CI 27% to 50%) of 74 patients: 3 (16%; 95% CI 3% to 40%) of 19 with delirium and 25 (46%; 95% CI 32% to 59%) of 55 with cognitive impairment without delirium. Emergency physicians altered management in none of the study patients on the basis of survey results. Five (26%; 95% CI 9% to 51%) of the 19 patients with delirium were discharged to home. Of these 5 patients discharged to home with unrecognized delirium, 1 presented with fall, 2 returned 3 days later and required hospitalization, and 1 with a history of colon cancer was given a new diagnosis of metastatic disease 4 days after the initial ED visit. Conclusion: Mental status impairment is highly prevalent in older ED patients. There is a lack of recognition by emergency physicians of mental status impairment in this group. Screening tools for mental status impairment in the ED did not substantially alter the care of elderly patients with mental status impairment. [Ann Emerg Med. 2003;41:678-684.] 678 ANNALS OF EMERGENCY MEDICINE 41:5 MAY 2003

INTRODUCTION Mental status impairment is highly prevalent among elderly emergency department patients. 1-4 These patients might carry an increased risk for adverse outcome after ED discharge. 3 Patients with delirium often have acute underlying illnesses and have been shown to have higher morbidity and mortality rates than their counterparts without delirium. 5-8 Patients with dementia might have difficulty with medication and discharge instruction compliance, which can also result in increased morbidity and mortality. In addition, the presentation of impaired mental status in the elderly might be subtle, making it difficult for the unsuspecting emergency physician to detect. Prior studies have suggested poor recognition of mental status impairment by emergency physicians. 1-3 However, although these studies prospectively screened for mental status impairment, they addressed recognition by using retrospective methodologies and ED chart reviews. The findings were supported by a lack of specific referrals by emergency physicians to address mental status impairment and by the significant number of patients with delirium who were discharged to home. 1 In response to these findings, a recent editorial suggested that if emergency physicians were made aware of mental status impairment, they would take appropriate action in evaluating the complaint and make the appropriate disposition and follow-up arrangements. 9 We designed this prospective interventional study with 2 major objectives. The first was to determine the effect of screening examination results for mental status impairment, when presented to the emergency physician, on the care plans of older ED patients. The second was to prospectively assess emergency physician recognition of mental status impairment in this group of ED patients. MATERIALS AND METHODS This was a prospective interventional study involving a convenience sample of older patients presenting to an ED between July 2000 and November 2001. Sampling periods were varied to include day, night, weekday, and weekend shifts, with frequencies based on the usual ED presentation times of older patients. This study was reviewed and approved by the hospital institutional review board. The study was conducted at an urban teaching hospital with approximately 55,000 ED visits per year and an affiliated ED residency program. Residents from several specialties rotate through the ED and are involved in patient care. All patients aged 70 years or older presenting to the ED during the study period were eligible for enrollment. Patients were excluded if they refused to participate, were critically ill, were unable to communicate or cooperate with data acquisition, or did not speak English in the absence of an acceptable translator. Only the initial visit was included for patients presenting to the ED more than once. Verbal informed consent was obtained for all patients participating in the study and from proxies or other family members when available. Consent was also obtained from emergency physicians participating in the study. The institutional review board waived the requirement for written informed consent. Eligible and consenting patients were evaluated for mental status impairment by using the previously validated Confusion Assessment Method 10 and Orientation Memory Concentration 11 screening tools. Proxies and family members, when available, were also interviewed regarding Confusion Assessment Method elements to account for the fluctuating nature of delirium. Initial screens were observed by the primary investigator to ensure reliability. Patients and families were also interviewed regarding past history of dementia, current living arrangements, and availability of home health care. Attending emergency physicians, blinded to screening results, were interviewed to assess for recognition of mental status impairment. Interviews were conducted after the emergency physician had determined patient disposition and care plan but before patient discharge from the ED. Additional questions were included to aid in blinding physicians from the purposes of the study. Planned patient dispositions and referrals were also recorded at this time. Results of the Orientation Memory Concentration and Confusion Assessment MAY 2003 41:5 ANNALS OF EMERGENCY MEDICINE 679

Method surveys were then unblinded: emergency physicians were informed of positive or negative scores for delirium or cognitive impairment without delirium. Emergency physicians were then reinterviewed regarding any change in care on the basis of survey results. There were 16 attending emergency physicians eligible to participate in the study. All were residency trained and board certified or board eligible in emergency medicine. The mean caseload per treating physician during the study period was 2.28 patients per hour (range 1.85 to 2.70; median 2.39). A change in care resulting from the use of the screening tools was recorded if there were any changes in a patient s disposition, diagnostic evaluation, or referrals after presentation of the survey results to the emergency physician. Physician recognition of mental status impairment was determined prospectively by comparing answers obtained from physician interviews with results of the Confusion Assessment Method and Orientation Memory Concentration surveys as the criterion standard. Standardized scores on the Confusion Assessment Method survey for the detection of delirium 10 and the Orientation Memory Concentration survey for the detection of cognitive impairment 11 were used to determine the prevalence of mental status impairment. Delirium was scored if patients exhibited features 1, 2a, and 2b from the Confusion Assessment Method in addition to abnormalities in either feature 3 or 4. Weighted scores of 11 or more on the Orientation Memory Concentration test were indicative of at least moderate cognitive impairment, whereas scores of 21 or greater were indicative of severe impairment. Patients with positive scores on both surveys were categorized as having delirium but excluded from the cognitive impairment without delirium category. This was to account for difficulties in the accuracy of cognitive assessment and dementia in the presence of delirium. Patients with positive scores for cognitive impairment without delirium and who had no prior history of dementia were considered newly discovered cases of probable dementia. Changes in care resulting from survey use and prevalence data are reported as proportions with 95% confi- dence intervals (CIs). Sensitivity and specificity of emergency physician recognition of mental status impairment with 95% CIs and relative risk ratios for hospital admission are also reported. Data were not collected on individual emergency physicians and are reported as aggregate data only to comply with the institutional review board requirement to protect physician confidentiality. RESULTS Three hundred twenty-seven eligible patients were screened, of whom 56 were subsequently excluded (Table 1). Of the remaining 271 patients, 126 (46%) were black, 143 (53%) were white, and 2 (1%) were Hispanic. One hundred fifty-two (56%) patients were female. Age ranged from 70 to 102 years, and mean age was 77.9±5.8 years. Three patients resided in extendedcare facilities and 6 in assisted living centers, and the remainder lived at home either alone or with family. The prevalence of mental status impairment is summarized in Table 2. Sixteen (6%) patients had positive scores on both the Orientation Memory Concentration and Confusion Assessment Method surveys. Two of these patients had a known history of dementia. The mean age of patients without mental status impairment was 77 years. The mean age of patients with mental status impairment was 80 years. Prospective recognition of mental status impairment by emergency physicians is summarized in Table 3. For Table 1. Patient participation. Participation No. (%) Ineligible 56/327 (17) Prior enrollment 5 Incomplete data 6 Refused 21 Unable to cooperate with survey 15 Non-English speaking 5 Critically ill 4 Completed interview 271/327 (83) 680 ANNALS OF EMERGENCY MEDICINE 41:5 MAY 2003

patients with cognitive impairment without delirium, physicians were more likely to recognize an abnormality in mental status if the patient was known to have a past medical history of dementia (8/9 [89%; 95% CI 52% to 100%] patients with past history of dementia compared with 17/46 [37%; 95% CI 23% to 52%] patients with no past history of dementia). The overall hospital admission rate was 39% (105/ 271 patients; Table 4). The presence of mental status impairment did not affect the chance of admission. Overall, 31 (42%) of 74 patients with mental status impairment were admitted compared with 74 (38%) of 197 patients for those with no impairment (relative risk 1.12; 95% CI 0.81 to 1.54). However, patients with delirium (11/19 [58%]) were 1 1 2 times as likely to be admitted to the hospital than those without delirium (94/252 [37%]; relative risk 1.55; 95% CI 1.02 to 2.35). In addition, 45 of 271 patients were admitted to the ED observation unit. These included 7 of the 55 patients with cognitive impairment without delirium and 3 of 19 with delirium. Changes in patient management resulting from the screening examinations are summarized in Table 5. No change in management occurred for any patient in the study population. Five of the 19 patients with delirium were discharged to home. Of these 5, 1 presented with fall, 2 others returned to the same ED 3 days later and were hospitalized, and 1 with a known history of colon cancer on follow-up 4 days later was given a new diagnosis of metastatic disease. Table 2. Prevalence of mental status impairment in the ED. Prevalence Population No. (%) (N=271) 95% CI All patients with mental status impairment 74 (27) 22 33 Cognitive impairment without delirium 55 (20) 16 25 Delirium 19 (7) 4 11 Table 4. Patient disposition from the ED. ED Observation Admissions, Unit, Discharges, Population No. (%) No. (%) No. (%) All patients 105/271 (39) 45/271 (17) 121/271 (45) Mental status impairment 31/74 (42) 10/74 (14) 33/74 (44) Delirium 11/19 (58) 3/19 (16) 5/19 (26) Cognitive impairment 20/55 (36) 7/55 (13) 28/55 (51) without delirium Table 3. Prospective recognition of mental status impairment. Sensitivity of Recognition by Emergency Physicians Specificity of Emergency Physician Diagnosis Nature of Impairment No. (%) 95% CI No. (%) 95% CI All forms of mental status 28/74 (38) 27 50 177/197 (90) 86 94 impairment Delirium 3/19 (16) 3 40 248/252 * (98.4) 96.0 99.6 Cognitive impairment 25/55 (46) 32 59 197/216 (91) 87 95 without delirium * Includes 3 patients with moderate or severe impairment on the Orientation Memory Concentration test but negative results for delirium. Table 5. Change in patient management resulting from screening examinations. Change in Management Made by Emergency Physicians Nature of Impairment No. (%) 95% CI All patients with mental status impairment 0/74 (0) 0 5 Delirium 0/19 (0) 0 18 Cognitive impairment without delirium 0/55 (0) 0 6 Five (26%; 95% CI 9% to 51%) of 19 patients with delirium were discharged to home. MAY 2003 41:5 ANNALS OF EMERGENCY MEDICINE 681

Of the 28 patients discharged home with cognitive impairment without delirium, 22 had no known history of dementia, whereas 3 were already institutionalized or in assisted living centers. A total of 46 of the 55 cases of cognitive impairment without delirium (84%; 95% CI 71% to 92%) were considered newly discovered in the ED during this study (patients with no prior history of dementia). DISCUSSION Our study, which is one of the first to prospectively assess the recognition of mental status impairment by emergency physicians, reveals that mental status impairment in older persons is both highly prevalent and poorly recognized. The substantial prevalence rate of mental status impairment in this group is in concordance with previous studies. 1-4 Three prior studies 1,4,12 reported that between 26% and 40% of all ED elders have some form of mental status impairment. Delirium alone has been shown to affect nearly 1 in 10 of these patients. 1-3 Other forms of cognitive impairment (eg, dementia) have been found in approximately 1 in 6 patients without delirium. 1,4 Remarkably, nearly 70% of the patients in this latter group have no prior history of dementia, making them potentially new cases discovered in the ED. 1 Our results are very consistent with these prior findings. Unfortunately, emergency physician recognition of mental status impairment in elders is suboptimal at best. A recent study by Elie et al 2 reported that emergency physicians were correctly identifying only 35% of elderly patients with delirium. Hustey and Meldon 1 found that, although 40% of ED patients with delirium had some documentation of mental status impairment, only 13% were correctly identified as having the syndrome. Lewis et al 3 found a similar lack of recognition of delirium by emergency physicians. Our study also reports similar findings. The potential for serious clinical consequences in patients with mental status impairment is high. Patients with dementia might have difficulty relaying accurately their history of present illness, omitting important de- tails that might lead to suboptimal care. The presence of dementia in the elderly patient can also affect medication and discharge instruction compliance, 12 increasing the risk of morbidity and mortality after ED discharge. Although less than 1% of all dementia is considered potentially reversible, those with chronic and degenerative dementia might still benefit from a variety of treatment options that slow disease progression and prolong independence. 13,14 Early referral for further evaluation and treatment might be beneficial. Patients with dementia are also at increased risk for falls. 15 Recognizing these patients could lead to interventions 16 (eg, medication reviews, home safety assessments) that might reduce this risk and possibly prevent further injury. Patients with delirium are also at risk. These patients often have an acute underlying illness necessitating hospitalization and have higher morbidity and mortality rates than counterparts without delirium. 5-8 Confusion might also contribute to difficulty with medication and discharge instruction compliance. In addition, patients with delirium might be prone to ED recidivism. 17 Delirium is an acute medical emergency, and strong consideration should be given toward hospitalizing these patients from the ED. However, our study results concur with those from prior studies in showing that a large proportion of patients with this condition are being discharged to home. 1 One reason given to explain this pattern of care is the lack of recognition of delirium by emergency physicians in older patients. 1,9 A recent editorial suggested that if emergency physicians were made aware of mental status impairment, they would take appropriate action in evaluating the complaint and make the appropriate disposition and follow-up arrangements. 9 In contrast, our study suggests that the management of patients with known delirium might also be a quality-of-care issue: although the emergency physicians failed to identify any of the 5 patients with delirium discharged from the ED in our study, no disposition change was made after they were informed of the survey results. Two of these patients returned to the ED within 3 days and required hospitalization, and a third was given a new diagnosis of metastatic cancer on follow-up. These findings might suggest a need for further 682 ANNALS OF EMERGENCY MEDICINE 41:5 MAY 2003

education of emergency physicians regarding the significance of delirium in this population. The mental status screening examinations used in our study have been well validated. The Confusion Assessment Method for delirium by Inouye et al 10 has been validated against structured psychiatric interviews, with a sensitivity of 94% to 100% and a specificity of 90% to 95% for the detection of delirium. It has also been shown to have a high interobserver reliability. 10 The Confusion Assessment Method evaluates the presence of 4 criteria to differentiate delirium from dementia: acute onset and fluctuating course, inattention, disorganized thinking, and altered level of alertness. 14 It can be easily administered in less than 5 minutes. 10 The Orientation Memory Concentration test for cognitive impairment has also been previously validated 11 and can be easily administered in the ED in less than 2 minutes. 12 It is reliable, valid, and has a better sensitivity for milder levels of impairment than the Short Portable Mental Status Questionnaire. 18,19 The brevity and ease of use of these screening tools makes targeted screening for mental status impairment feasible in the ED. One limitation of our study is that physicians were not educated regarding the reliability of the screening tools and might not have deemed the surveys a reliable method of screening for mental status impairment. This could have influenced the lack of effect the surveys had on patient care. The actual prevalence of mental status impairment in our population might also be significantly underestimated. Patients who could not be interviewed because of critical illness or inability to cooperate with data acquisition were excluded from the study. This group might have had a much higher prevalence of mental status impairment than the general study population. The prevalence of newly discovered cognitive impairment without delirium might have been overestimated. Although patients and family members were interviewed regarding past history of dementia, hospital records were not reviewed. Finally, our population was a convenience sampling, and thus a sampling bias cannot be excluded. Our relatively small sample population also contributed to limited statistical significance in some subgroup analyses. Future studies should examine the effect of mental status impairment on morbidity and mortality in older ED patients. Mental status impairment is both common and poorly recognized in older ED patients. The use of screening examinations to detect mental status impairment did not significantly alter care plans. Further studies examining the effect of mental status impairment on the outcomes of older ED patients are warranted. Author contributions: FMH and SWM conceived the study and designed the protocol. MDS significantly contributed to protocol revision. FMH supervised the conduct of the study and data collection and managed the data, including quality control. MDS and CKL were responsible for patient enrollment and assisted with data collection and management. FMH analyzed the data. SWM provided statistical advice. FMH drafted the manuscript, and all authors contributed to its revision. FMH takes responsibility for the paper as a whole. Received for publication October 7, 2002. Revision received November 22, 2002. Accepted for publication December 4, 2002. This article was presented in part at the Society for Academic Emergency Medicine Scientific Assembly, St. Louis, MO, May 2002. Dr. Meldon was supported in part by an American Geriatrics Society/Hartford Foundation Jahnigen Career Development Scholars Award. Address for reprints: Fredric M. Hustey, MD, Department of Emergency Medicine-E-19, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195; 216-445-4558, fax 216-444-1703; E-mail husteyf@ccf.org. REFERENCES 1. Hustey FM, Meldon SW. The prevalence and documentation of impaired mental status in elderly emergency department patients. Ann Emerg Med. 2002;39:248-253. 2. Elie M, Rousseau F, Cole M, et al. Prevalence and detection of delirium in elderly emergency department patients. CMAJ. 2000;163:877-881. 3. Lewis LM, Miller DK, Morley JE, et al. Unrecognized delirium in ED geriatric patients. Am J Emerg Med. 1995;13:142-145. 4. 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